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SERVICE WORK <br /> � C§eanyech <br /> ORDER f <br /> Environmental Inc. 33974 <br /> 2581 S. Sunland Avenue • Fresno, CA 93725 <br /> • ': Phone: 1-800-531-9683 � ! <br /> MM www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS C <br /> Name I.�, r. frrr.�ot Sf 1r;s Co 5:ftt Customer Purchase Order# <br /> Address r; r, ry Sales Representative <br /> �. 1 1 llsclstl}�r N <br /> City State Zip I oCi cf,, 11[? ;_ Phone # I <br /> EPA ID # Ck #/COD <br />_t • . Manifest # Used Oil (��� Manifest# Non Haz Wastewater <br /> C <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION i G <br /> ¢ PART# U.S. DOT SHIPPING DESCRIPTION G1TY. UOM INT PRICE SUB-TOTAL <br /> 0 <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> ¢ <br /> Z 10013500 USED ANTI-FREEZE NON•RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> }. 10043000 NON-HAZARDOUS WASTEWATER GAL f <br /> m <br /> W Man.Fee MANIFEST DOCUMENT FEE EA. L(s <br /> Ir- <br /> UJ <br /> psi <br /> 0 <br /> GENERATOR USED OIL CERTIFICATION a <br /> IW USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> M facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> that the contents of this consignment are full and accurate) described above b the proper DOT shipping name and are classified,packaged, O <br /> 't 9 Y Y Y P P PP 9 P 9 <br /> marked, labeled and are in all aspects in proper condition for transport by D.O.T. standards.All relevant information regarding known or <br /> suspect hazards associated with this waste have been disclosed. I certify that the waste minimization statement identified in 40 CFR 26227 <br /> (a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) us true. Waste materials which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> •�: !. '. 1�1'l LJi�.' X <br /> _ TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE I C <br /> I hereby certify that I have read and have the authority to bind Ithe above rs ed generator to the terms found on the front and the back of <br /> this form. I hereby certify this,and all attached documents contain true and accurate descriptions of the waste including that the waste is <br /> segregated and not comingled with other waste streams.As the Generator, I acknowledge that our site EPA ID # is active. This document <br /> 1' serves as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Facility Generator <br /> •I •: Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams. <br /> I declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> FW- CleanTech Environmental,Inc. PRINT FUUL NAME <br /> AE / e <br /> ¢ <br /> 0 2581 S.Sunland Avenue <br /> can Fresno, CA 93725 <br /> Y EPA ID #:CAL000 68136 <br /> RIVER'S SIGNATURE <br /> TANKER# DATE <br /> cs RECEIVING FACILITY 0 <br /> W Z Fes- The checked box is the designated recycling facility. <br /> I <br /> G > � <br />`.� W CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 O <br /> ¢ W Q d CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID#: NVR000090050 <br /> nW ¢ LL ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N. Las Vegas, NV 92126 <br /> 771I <br />